Comprehensive SOAP - GERDComprehensive SOAP - GERD, Exams of Nursing

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Comprehensive SOAP - GERD

SOAP Note: Gastroesophageal Reflux Disease (GERD) Patient Information

• Name: [Patient Name]
• DOB: [Date of Birth]
• Date: [Current Date]
• Time: [Time]
• Location: Outpatient Clinic SUBJECTIVE (S) Chief Complaint (CC): "Burning in my chest and a sour taste in my mouth almost every night for the past 3 months." History of Present Illness (HPI): [Name] is a [age]-year-old [M/F] with a history of intermittent heartburn for 2 years, now presenting with worsening symptoms over the past 3 months. Patient describes a retrosternal burning sensation (heartburn) that occurs 30–60 minutes after meals, particularly after large or fatty meals, and worsens

when lying down or bending over. Symptoms are also reported at night, often awakening the patient from sleep. Associated symptoms include regurgitation of sour/bitrous fluid into the mouth, occasional globus sensation (feeling of lump in throat), and mild chronic cough, especially upon waking. Patient denies dysphagia, odynophagia, hematemesis, melena, or unintentional weight loss. Symptoms are partially relieved by over-the-counter antacids (Tums) and famotidine 20 mg, but relief is short-lived (<2 hours). No previous prescription therapy for GERD. Patient reports avoiding tomato- based foods and coffee with mild improvement. Review of Systems (ROS):

• General: Denies fever, chills, night sweats, weight loss.
• HEENT: Reports morning hoarseness and sensation of needing to clear throat frequently. Denies dental erosions noted.
• Cardiovascular: Denies chest pain (non- burning), palpitations, or shortness of breath. Burning sensation is not exertional.

• No known drug, food, or environmental allergies. Social History:
• Lives with spouse; works as a software developer (sedentary, long hours)
• Diet: High-fat, large dinners; often eats within 2 hours of bedtime; daily coffee (3 cups), occasional alcohol (2–3 beers/week), no smoking or illicit drugs
• Exercise: Walks 15 min daily Family History:
• Father: GERD, HTN; Mother: Obesity, Type 2 DM; No known esophageal or gastric cancer. OBJECTIVE (O) Vital Signs:
• BP: 128/82 mmHg
• HR: 78 bpm, regular
• RR: 14/min
• Temp: 98.4°F (36.9°C)

• SpO2: 98% RA
• BMI: 32. Physical Exam:
• General: Alert, well-nourished, no acute distress.
• HEENT: Oropharynx clear, no dental erosions, no mucosal lesions. Hoarse voice noted.
• Neck: Supple, no lymphadenopathy, no thyromegaly.
• Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. No chest wall tenderness.
• Respiratory: Clear to auscultation bilaterally, no wheezes or crackles.
• Abdomen: Soft, non-tender, non-distended, normal bowel sounds. No hepatosplenomegaly or masses.
• Extremities: No clubbing, cyanosis, edema. Labs & Diagnostic Studies:
• None today. Consider: o Upper endoscopy (EGD) if alarm features present or PPI trial fails.

esophageal sphincter relaxation). Absence of alarm features (dysphagia, weight loss, bleeding) supports non-urgent management. No previous PPI trial. Differential Diagnoses (ruled out or unlikely):

• Eosinophilic esophagitis (no dysphagia or food impaction)
• Peptic ulcer disease (no epigastric pain, no NSAID use)
• Cardiac chest pain (non-exertional, positional, relieved by antacids)
• Gastroparesis (no early satiety or nausea)
• Functional heartburn (no response to acid suppression would suggest this) PLAN (P) Treatment:

1. Lifestyle Modifications (first-line, reinforce): o Elevate head of bed 6–8 inches (blocks or wedge pillow) o Avoid eating within 3 hours of bedtime

o Weight loss: target 5–10% body weight o Avoid triggers: fatty/fried foods, chocolate, caffeine, alcohol, carbonated beverages, citrus, tomato-based products o Small, frequent meals rather than large meals

1. Pharmacotherapy: o PPI trial (standard of care for moderate GERD): ▪ Omeprazole 20 mg once daily, 30– 60 minutes before breakfast for 8 weeks ▪ If partial response, increase to 40 mg daily or switch to esomeprazole 40 mg o Continue famotidine 20 mg at bedtime if needed for nocturnal breakthrough (though PPI is preferred)
2. Medication Review: o Lisinopril is not strongly linked to GERD but monitor; do not change without primary care. Diagnostic Plan:

• Return to clinic in 8 weeks for medication response assessment.
• Earlier if symptoms worsen or alarm features develop.
• Consider GI referral if refractory symptoms or abnormal EGD. Billing/CPT Consideration:
• ICD-10: K21.9 (GERD without esophagitis) or K21.0 (with esophagitis – if known)
• E/M code: 99213-99214 (moderate complexity) Slide 1: Title Slide Comprehensive SOAP Note: Gastroesophageal Reflux Disease (GERD)
• [Your Name/Institution Name]
• [Date]
• Clinical Skills / Gastroenterology / Primary Care Slide 2: Case Introduction Chief Complaint

"Burning in my chest and a sour taste in my mouth almost every night for the past 3 months." Patient Demographics

• Age: [Insert age]
• Sex: [M/F]
• BMI: 32 (Obese)
• PMH: Hypertension, Obesity Slide 3: HPI – Key Features Symptom Characteristics
• Retrosternal burning (heartburn) – 30 – 60 min post meals
• Worsens with: Lying down, bending over, large/fatty meals
• Nocturnal awakening
• Regurgitation of sour fluid
• Globus sensation (lump in throat)
• Morning hoarseness + chronic dry cough Alarm Features (Denied)
• ❌ Dysphagia

• Hypertension (lisinopril)
• Obesity Social History
• Sedentary desk job
• Large dinners <2 hours before bedtime
• Daily coffee (3 cups), occasional alcohol
• No smoking Family History
• Father: GERD, HTN
• Mother: Obesity, DM type 2 Slide 6: Medications & Allergies Current Medications Medication Dose Frequency Lisinopril 10 mg Daily Famotidine 20 mg PRN (3-4x/week) Tums PRN Up to 2 tablets/day

Allergies: None Previous PPI trial? No Slide 7: Physical Exam Findings Vitals

• BP 128/82 | HR 78 | RR 14 | O2 98% | BMI 32 Key Exam Findings
• HEENT: Hoarse voice, oropharynx clear
• Chest: No tenderness, clear lungs
• Abdomen: Soft, non-tender
• No clubbing, edema, or lymphadenopathy Slide 8: Assessment – Primary Diagnosis Gastroesophageal Reflux Disease (GERD) – Moderate severity Atypical features:
• Laryngeal symptoms (cough, hoarseness)

First-line (reinforce all)

• 🛏️ Elevate head of bed 6–8 inches
• ⏰ No eating within 3 hours of bedtime
• 🍽️ Small, frequent meals
• ⚖️ Weight loss: target 5–10%
• 🚫 Avoid triggers: o Fatty/fried foods, chocolate o Caffeine, alcohol, carbonated drinks o Citrus, tomato-based products Slide 11: Plan – Pharmacotherapy PPI Trial (Standard of Care) Omeprazole 20 mg daily 30 – 60 minutes before breakfast × 8 weeks If partial response:
• Increase to 40 mg daily OR
• Switch to esomeprazole 40 mg Nocturnal breakthrough:
• Famotidine 20 mg at bedtime (PRN)

Slide 12: Plan – Diagnostic & Follow-up Immediate EGD? ❌ No (no alarm features) Reassess at 8 weeks: Response Action Complete resolution Step-down to lowest effective dose or o demand Persistent symptoms Refer for EGD (r/o erosive esophagitis, Barrett's) Alarm symptoms to report immediately:

• Dysphagia, odynophagia
• Hematemesis, melena
• Unintentional weight loss Slide 13: Patient Education Points
• GERD is chronic – treatment controls, not cures
• Take PPI before breakfast , not PRN